Director of Quality Management @ Aetna Better Health, Illinois
Vice President of Quality Management @ Amerigroup
Director of Quality and Compliance @ Magellan Health Services
BA, Nursing @
Augustana University (SD)
Outcomes driven managed care executive with expertise in leading multiple cross functional teams in large geographically spread organizations resulting in measurable and sustained administrative cost savings (averaging $1.5 million per project) and reduction of process defects (50-100%) for the healthcare, insurance operations, information technology and sales industries. Demonstrated advanced knowledge of process engineering methodologies: Six Sigma, LEAN,
Outcomes driven managed care executive with expertise in leading multiple cross functional teams in large geographically spread organizations resulting in measurable and sustained administrative cost savings (averaging $1.5 million per project) and reduction of process defects (50-100%) for the healthcare, insurance operations, information technology and sales industries. Demonstrated advanced knowledge of process engineering methodologies: Six Sigma, LEAN, Kaizen, Quality Functional Deployment, and Plan-Do- Check-Act (PDCA) leading to prototypical and innovative solutions. Six-Sigma Black Belt certified.
Business Process Engineering
Large Cross Functional Inititiatives
Malcom Baldrige Board of Examiners (state and national) 2003 -2011
Performance Measures Development and Reporting
Director of Quality Management @ Direct quality management program for large Medicaid and Medicare Managed Care Organization. Lead NCQA accreditation team, direct strategies to exceed pay for performance healthcare outcome based metrics. Manage a team of ten talented individuals who support the integration and alignment of the health plan's quality objectives. From May 2015 to Present (6 months) Greater Chicago AreaVice President of Quality Management @ Provided leadership for implementation of the comprehensive clinical quality management program. Directed company wide quality management scorecard including statistical analysis and validation of clinical quality improvement data and reports. Responsible for innovative approaches to achieve targeted improvement goals associated with HEDIS measures. Monitored compliance and accreditation activities including NCQA, EQR, and URAC. From May 2013 to December 2014 (1 year 8 months) Overland Park, KansasDirector of Quality and Compliance @ *Successfully led organization to achieve full NCQA accreditation as a Medicaid MBHO
*Responsible for all aspects of the quality and compliance program for the Care Management Center.
*Directed quality management team in designing, implementing, and monitoring quality operations *Responsible for performance measurements and analysis, customer reporting,
*Provided compliance oversight including review of policies, and procedures, quality of care concerns tracking, coordination of satisfaction surveys, performance guarantee tracking,
*2012 URAC National Best Practice Honorable Mention. Enhanced support for families of children with mental illness; resulting in reduced 30 day readmission rates and improved member satisfaction. From September 2010 to May 2013 (2 years 9 months) West Des Moines, IowaDirector Provider Reimbursement @ Senior project manager directing the development and implementation of provider reimbursement for a 26 billion dollar healthcare contract, providing services for 3 million lives in an eleven state area.
•Provided business oversight for integration of government requirements for provider claims payment into new and existing technology resulting in a 10 million dollar administrative cost savings opportunity associated with ambulatory surgical claims process.
•Led multiple cross functional teams in the creation of provider reimbursement processes by developing a process to facilitate member movement through transplant related stages of care resulting in increased accuracy of benefit application and provider reimbursement associated with Centers of Excellence. From June 2009 to June 2010 (1 year 1 month) Operational Excellence Manager @ Strategic Consulting, including business plan & sales strategy development.
Executive level healthcare program and account manager with advanced training and experience in Quality and Process system development. An integration and deployment leader with substantiated and sustained success in leading prototypical and corporate wide cross-functional initiatives. Highly skilled interpreter of business and customer requirements into clearly defined measurable objectives. Key strengths include:
•Quality Program Design and Development
•Certified Six Sigma Black Belt
•Innovative and Autonomous Leader
•Analytics and Dashboard Development
•Skilled Facilitator From April 2009 to July 2009 (4 months) Process Excellence Leader, Six Sigma Black Belt @ Directed quality management program. Successfully led multiple integration and process improvement initiatives across wellness, disease, and case management programs.
•Developed and led quality management program by providing oversight of organizational process and outcome measures, project selection and project oversight. Seven months following launch of program, the program was recognized as a best practice during an URAC (Utilization Review Accreditation Committee) audit.
•Standardized employer reporting process using Kaizen and Lean methodologies, achieving a 33 percent reduction in report generation process cycle time (21 to 14 days) with the insertion of standardized work and process controls. From October 2007 to April 2009 (1 year 7 months) Consultant Business Project Management @ Provided business process leadership and representation for Sales and Call Center initiatives.
Developed Request for Proposal, (RFP) for an organization-wide single platform telephonic call monitoring system integrating the needs of over 30 business entities achieving an estimated one million dollars in annual administrative costs savings. From February 2006 to October 2007 (1 year 9 months) Project Office Manager @ Successfully managed talented hybrid project team accountable for company’s largest client’s benefit implementation services (accountable for ten million dollars revenue per year).
•Led introduction of project management standard work processes improving resource management and project delivery, increasing project revenue by 90% or $165K per month. Team utilization increased from 65 % to 85%. From February 2005 to January 2006 (1 year) Process Excellence Leader @ Six Sigma Black Belt, ASQ and CPHQ certified. Managed multiple and diverse cross functional projects.
- Project team migrated company from paper ID cards to light plastic, resulting in an annual savings of $250K.
- Development of a Bariatric Centers of Excellence Application Process
- Benefit savings projects, Durable Medical Equipment and Partner Plan Claims Billing Process, both achieving > $3 Million in benefit savings during thier 18 month control periods. From September 1986 to February 2005 (18 years 6 months) Performance Excellence Leader, Six Sigma Black Belt @ Leader and change agent of multiple enterprise-wide healthcare delivery cross-functional projects in areas of fulfillment, medical management, and claims operations.
• Mentored Green Belts projects achieving either a 50% defect reduction or $25K in savings. Projects involved claims processing, accounting, and marketing material generation.
• Led centralization and ultimately outsourced production of health care identification cards resulting in a 100%reduction in process defects and annual savings of 550 thousand dollars.
Consultant Healthcare Data Analytics 1996 – 1999
Performed benefit utilization analysis for sales, marketing, underwriting, and employer groups enabling anticipatory knowledge used for premium and reserve adjustments.
Utilization Review Senior Nurse Reviewer 1989 – 1996
Applied managed care criteria and benefit knowledge to healthcare service requests.
Medicare Part A Compliance Consultant 1986 – 1989
Audited Home Health providers regarding compliance with Medicare Part A requirements. From 1986 to 2004 (18 years)
MBA, Marketing and IT @ Iowa State University From 1999 to 2001 BA, Nursing @ Augustana University (SD) From 1975 to 1979 Karen Kramme is skilled in: Cross-functional Team..., Managed Care, Healthcare, Six Sigma, Medicare, Leadership, Business Process..., Healthcare Management, Quality Management, Medicaid, Program Management, Utilization Review, Health Insurance, NCQA, Disease Management, Healthcare Consulting, Utilization Management, Management, Informatics, HIPAA, Data Analysis, Health Policy, Strategic Planning, EHR, Process Improvement, Quality Improvement, Insurance, HEDIS, Employee Benefits, Case Managment, Software Documentation, Hospitals, Medicaid Managed Care, EQRO, Process Engineering, Pay for Performance, CAHPS, Project Management, Healthcare Industry, Policy, Patient Advocacy
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